The Healthy People 2020 Blueprint for National Health Goals program was produced and published by the United States Department of Health and Human Services in 2010 to “achieve health equity, eliminate disparities, and improve the health of all groups.”1 These groups are defined as race and ethnicity; gender; socioeconomic status; disability status; lesbian, gay, bisexual and transgender (LGBT) identity; and geography.
The Fenway Institute, an interdisciplinary center for research, training, education, and policy development, focusing on national and international health issues for traditionally underserved communities, defines the T of LGBT as those persons who identify as transgender, an umbrella term for people whose gender identity and/or gender expression differs from their assigned sex at birth (ie, the sex listed on their birth certificate). Gender identity is a person’s innate, deeply felt psychological identification as a man, woman, or another identity outside of the gender binary that may not correspond to the person’s external body.2 Gender identity, therefore, is different, distinct, and not to be confused with sexual identity or sexual orientation. Sexual identity/orientation is defined by the National LGBT Health Education Center as “how one identifies their physical and emotional attraction to others. Sexual identity/orientation involves three components: attraction, behavior, and identity.”3 For data, analytic and research purposes, gender identity and sexual identity are now uniformly categorized as sexual and gender minorities (SGMs).
Risks Specific to Transgender People
The burden of cancer, as has been noted by recent, albeit limited, research mostly from state-level population surveys, affects SGM persons disproportionately more than their heterosexual counterparts.4 One primary reason for the lack of research is that the SGM community has not been included in the National Institute of Health (NIH) national cancer registries.4 There are complex and multifaceted behavioral, political, and socio-economic factors that result in higher incidence rates for some cancers in SGM persons. For transgender people, some of these factors are uniquely significant, such as a lack of awareness about their own health needs, which can prevent transgender persons from being screened for certain cancers. For example, people who undergo sex-reassignment surgery retain a small amount of tissue from their original reproductive organs; therefore, a trans woman may be at risk for prostate cancer, and a trans man may be at risk for ovarian cancer.5
Other factors include oncologists’ and other health care providers’ lack of knowledge about gender identity; insufficient training in cancer care for transgender patients; and unfortunately, discomfort with, disinterest in, and discrimination toward the transgender cancer community. Thus, many transgender persons avoid or delay pursuing health care because of past experiences within the health care system. According to a survey by the National LGBT Cancer Network and the National Center for Transgender Equality, which had 28,000 respondents, 50% of transgender persons surveyed reported teaching their medical providers about transgender health care, 19% were refused care due to their transgender identity, 28% postponed necessary medical care when sick or injured due to discrimination by health care providers, and 33% delayed or did not try to get preventive health care due to discrimination.
Some behaviors that are statistically more common in the transgender community are associated with a disproportionate risk for certain cancers, including higher rates of alcohol consumption, cigarette use, illegal substance use, and use or misuse of prescribed or self-administered hormone therapy, as well as a higher percentage of risk factors that are associated with unsafe sex (eg, depression, low self-esteem, relationship abuse, sex while drunk/high, and sexual abuse/assault), resulting in potential exposure to human papillomavirus (HPV), HIV, and hepatitis B.7 Cases of presumably hormone-related malignancies diagnosed in trans women after the initiation of medical or surgical gender affirmation include carcinomas of the breast and prostate, prolactinomas, and meningiomas. In trans men, published case reports describe cancers of the breast, ovaries, cervix, vagina, and endometrium.8